Wiring health services with sensors and EMR

Doctors, clinics, hospitals and patients are being brought together by electronics. It will be a revolution in healthcare, according to participants in a Jerusalem symposium.

AN ISRAELI doctor 370.
(photo credit:Baz Ratner/Reuters)

The time when we will all walk around with non-invasive, wearable medical sensors and use simple devices that will point to potentially harmful physiological changes is nearing.

Electronic medical records (EMR) are already making it possible to diagnose and monitor patients’ condition in the community clinic and any hospital. A newer development will be individuals monitoring their own health.

Alerts on high blood pressure, cholesterol and sugar will automatically be produced; a parent will place a put a CellScope device into his child’s eardrum to detect an infection, with a prescription for antibiotics being dispatched to his home to treat it. A respiratory monitor will detect early asthma spasms.

Irregular heartbeats will be detected through a sensor attached to the chest with a piece of tape, and transmitted to a call center over the phone.

But what about the economically and educationally disadvantaged who don’t have access to these services or the ability to understand and use them? The practice of medicine is about to change drastically, threatening to turn individuals into their own layman doctors. But physicians and medical students will argue that despite all the digital gadgetry, doctors will always be needed to listen, observe, counsel and prescribe.

An afternoon symposium on “Connected Health and Vulnerable Populations” was held recently at the non-profit Myers-JDC-Brookdale Institute at Jerusalem’s Givat Ram, with participants from Israel and abroad. It was organized by the institute’s Smokler Center for Health Policy Research, established in 1986 amid a national crisis in the health system and the effort to introduce universal health care.

“Information technology is crucial in the health system,” said Dr. Bruce Rosen, the center’s director. “But,” he added, “there are vulnerable people with different demographics than the majority, namely the elderly, the poor, those who live alone and are in a cultural or linguistic minority or in the periphery of the country.”

“Huge challenges face Israel’s great health system – the rise of private medicine, the manpower shortage, aging and so on, and they put all of us at risk,” added Myers-JDCBrookdale director Prof. Jack Habib, “but the most vulnerable parts of the population are at the most risk.”

All countries face the problem that health reform fails if it isn’t available to all in the country, pointed out Dr. Jonathan Javitt, a physician with expertise in information technology, health economics and public health at the National Security Health Policy Center at the Potomac Institue for Policy Studies.

“Americans spend more than 16 percent of their gross domestic product on healthcare, compared to only 7.5% in Israel. But Americans have a lower life expectancy than do Israelis, who are much more satisfied with their healthcare. There are only three options to control medical costs – deny care to some consumers, reduce payments to providers or use technology to reduce the need for expensive care,” said Javitt, who has been a member of the Jerusalem institute’s health advisory committee for 15 years and who is founder ad CEO of Telcare, a wireless communication/ medical technology company that connects patients and caregivers around the management of chronic illness.

“For 2,000 years, healthcare consisted of giving potions for acute conditions. In the past century it has been medications – and you either survived or died. For a hundred years, we have been treating mostly chronic illness such as congestive heart failure, ‘dropsy’ [swelling of soft tissues due to the accumulation of excess water] and diabetes. Before insulin was produced, kids with type 1 diabetes were starved so they could live longer.”

Today, continued Javitt, 70 percent of healthcare spending is on chronic illness. People who are economic and socially disadvantaged, living alone, or have chronic pulmonary disease are disproportionately suffering.

“How do we invent new system that deals with the problems of today? In 1988, we suddenly realized that we knew more about the healthcare system than we thought. Most Americans, but not all, had health insurance and left an electronic trail. If you went to one New York hospital or another, your chances of being alive six months after a coronary bypass depended on which hospital admitted you.

“You can use electronic data to identify medical errors. For example, you look at people who got a heart attack but never were given a beta blocker [to protect against a second heart attack]. Everybody does it now.

Electronic medical records are slowly becoming the rule in the US.”

Javitt noted that because Israel is a much smaller country and only has four public heath funds, that are very centralized, electronic medical systems took root. Maccabi Health Services was the first insurer to create a system of electronic records. By 2000, all four health funds had such systems. The success of the Israeli system persuaded president George H.W. Bush to do the same thing.

“Today,” said Javitt, “patients with chronic illness can be helped to manage their condition, avoid complications and superfluous hospitalization and have longer and more satisfying lives. Just a 10% reduction in diabetics’ blood sugar can reduce complications such as stroke, heart attack, blindness and amputation of limbs by 40%. This significantly reduces the need for hospitalization ad reduces costs.”

Connectiveness means that in the US, pharmacy chains can refill prescriptions by scanning labels, and can provide medication reminders to customers. Patients no longer have to be alone. “There is always somebody out there to help with healthcare,” Javitt noted.

The US expert looks forward to a future with medical sensors.

“It will be possible to identify patients who are not yet in trouble but will be if they are not treated early. Developers of sensor technology need a lot of imagination – to think out of the box. Missile identification technology was adapted to identify asthmatic children who need steroids, for example.”

Israeli hi-tech people are “full of good ideas, and sensors are inexpensive. The industry is perfect for Israeli minds and situations.”

But he noted that Israeli physicians “are as resistant to change as in the US. If they get paid by the visit, they won’t have financial incentives to go along with the revolution.

But if they do get paid, they will cooperate,” Javitt concluded.

DR. BOAZ Lev, the associate director-general of the Health Ministry in Jerusalem, has spent many years in the field of electronic medical records and information technology.

“I can’t predict what will happen in a decade. Things develop so quickly. We realize many of the benefits, but we don’t know what problems the new technologies will bring us.

We also don’t know what the ministry’s role, as a regulatory agency supervising the health system, will take.”

He suggested that it was the Justice Ministry, with its ideology of protecting privacy, put the brakes on medical data transfers.

“Israel could have had a connected medical community a decade ago. Today, we are collecting medical data from the four health funds. We set up the national health indicators initiative to monitor health problems in various sectors. We established the Ofek project to share electronic medical records between health funds and the hospitals. Justice Ministry lawyers remain suspicious of interactive medical data systems.

“They know that everybody checks their bank accounts and moves money around via the Internet, and nobody’s accounts have been emptied out, so they should realize that health data can be shared and privacy still protected.”

Coping with the outbreak of wild polio virus in Israel last year required the ministry to collect electronic data on the population, especially among Beduin in the south, said Lev.

“We knew who had been vaccination and even who had wild polio virus in their stools, that we traced to see who had been transmitting the virus through the sewage.”

ISRAEL IS very digitally sophisticated,” said Dr. Rachel Kaye, coordinator of Maccabi Health Services’ international center for R&D who has for over 10 years been at the center of successful efforts to promote cooperation in health information technology with the rest of the world.

“All the heath funds now have digital medical records, and any doctor can see everything that has been collected on his patients. Just as important is the fact that patients have the right to access their personal medical records with their test results, list of medications, data on vaccinations and so on. The challenge we face is to use the information intelligently, efficiently and effectively,” said Kaye.

“Yet we must always remember that access to a computer cannot substitute for human interaction between the physician and the patient. Prescriptions can be obtained efficiently by cellphones, but the chronically ill patient has to be monitored by his doctor.”

Kay also warned that very little in health promotion and disease prevention is being sought out by patients using their smartphones.

A CARDIOLOGIST at Clalit Health Services who heads its medical planning and development, Dr. Ilan Zelinger said it was much easier to wire Israel’s medical system than to do the same in the US.

“We all have ID numbers, the country is small and its health system highly centralized and regulated and there are only four public health funds.” The Ofek system, he said, “is very welcome, as it united not only the community clinics and hospitals but also medical care in the Israel Defense Forces. Linking all of this saves a lot of money, but we are missing psychiatric services, nursing homes, geriatric hospitals and private hospitals, foreign or illegal residents and medical tourists. We still need big chunks of aggregated data and then decide what to do with it.” Another problem is that different hospitals used different codes to describe the same medications and other things, he said.

SAUL SINGER, the former Jerusalem Post editorial writer who earned international fame when he co-authored with his brother-in-law the book Startup Nation, told the participants that he knew little about medicine.

“One hundred years ago, we were blind.

Now there is an explosion of sensing technology.

Decades from now, we will say that it’s unbelievable we lived without it all. We didn’t know what was going on in our bodies. People went to their doctors only when they didn’t feel well. It was very primitive. In the near future, we will reach the age of continuous monitoring, and it could save our lives.

Maybe we’ll be able to predict a heart attack three days before it occurs. We’ll be able to identify cancerous tumors when they are only half a centimeter in size. The technology is all there,” said Singer. “What’s holding us back are bureaucratic and legal problems.”

Israel is a natural place for this to happen, said Singer. “We can bring together all the pieces of the puzzle. The country that succeeds first will be the healthiest country and have technology that could be sold abroad.”

Israel, he concluded, should put this on its national agenda “just like the US aimed for reaching the moon.”

The symposium was held in memory of American Jewish healthcare pioneer Larry Lewin, who devoted decades to the effort to model comprehensive healthcare delivery and coverage, including as founder of the Lewin Group and serving on the board of Intermountain HealthCare, American’s largest non-profit hospital system. He was a member of the Smokler Center’s health advisory committee for five years and died two years ago. Although he focused his energies on US healthcare, in his last years he also promoted access to healthcare for all Israelis, especially those in the periphery.